Lecture 39 Learning disabilities and medicines management

What is a learning disability

Impaired Intelligence: A significantly reduced ability to understand new or complex information and to learn new skills.

Impaired Social Functioning: A reduced ability to cope independently.

Onset: Started before adulthood, with a lasting effect on development.

How do we measure IQ

Measurement

Assessed via tools like WAIS-IV. A Full Scale IQ (FSIQ) score of < 70 indicates a learning disability.

What is the prevalence of LD

Prevalence

This score falls two standard deviations below the mean, representing ~2% of the population.

In the UK, this equates to ~1.5 million people (905,000 adults).

What are some pointers of LD

• Pointers: Delayed developmental milestones, special schooling, needing support with daily living activities (ADLs), and significant communication difficulties.

What is the cause of LD

Antenatal

Perinatal

Perinatal

Aetiology (Antenatal): Any insult to the developing brain. Examples: Genetic conditions (e.g., Down Syndrome), congenital infections, or teratogens.

Aetiology (Perinatal): Events around birth. Examples: Birth asphyxia/hypoxia, severe prematurity.

Aetiology (Perinatal): Events around birth. Examples: Birth asphyxia/hypoxia, severe prematurity.

What are some major co-morbidities associated with LD

Epilepsy: ~40% have epilepsy (often refractory, high SUDEP risk).

Dementia: 2.5x higher dementia risk. In Down Syndrome, Alzheimer's risk is high, with onset in 40s-50s

Cardiovascular and metabolic diseases: Increased risk of heart disease, high blood pressure, and obesity, often linked to poorer diet, less exercise, and reduced access to health promotion.

Sensory impairment

Hearing/sight issue

Poor dental hygiene,

gastro-intestinal problems (GORD, dysphagia, GI cancers).

Generally describe the access to health for LD individuals

• Increased rate of mortality due to poor access, most of which are avoidable

What are some causes of these preventable deaths

• Communication difficulties (est. 50%).

• Lack of specialist understanding.

• Capacity issues.

• "Diagnostic Overshadowing" (symptoms blamed on LD).

• Negative perceptions / QoL judgements (e.g., DNARs).

How can we address these barriers

Annual Health Checks (AHC): For everyone >14 on the GP LD Register. A vital opportunity to review health and medication (e.g., using STOPP-START)

How can we make reasonable adjustments during appointments

Reasonable Adjustments: A legal requirement (Equality Act 2010). Examples: longer appointments, quiet/first appt, easy-read leaflets, carer input.

What is the role of LD nurses

LD Liaison Nurses: "Bridge the gap" in general hospitals. They support staff in making adjustments and navigating the Mental Capacity Act (MCA).

What is the mental capacity act 2005

designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment

2 stage capacity

4 point functional test

What is the 2 stage capacity test

The 2-Stage Test of Capacity

• Stage 1 (Diagnostic): Is there an impairment of, or disturbance in the functioning of, the person’s mind or brain?

• Stage 2 (Functional): Is the impairment sufficient that the person lacks the capacity to make that particular decision at that time?

What is the 4 point functional test

To have capacity, the person must be able to:

Understand the relevant information.

Retain the information.

Use or Weigh the information in the decision process.

Communicate their decision.

The 5 Key Principles of the MCA

1. Presumption of Capacity: Every adult is assumed to have capacity unless proven otherwise.

2. Support Decision-Making: All practicable support must be given to help someone make their own decision.

3. Unwise Decisions: A person is not to be treated as unable to make a decision merely because they make an unwise one.

4. Best Interests: Any act or decision made for a person lacking capacity must be in their best interests.

5. Least Restrictive Option: The option chosen must be the one that is least restrictive of the person's rights and freedom.

What are some hazards and side effects in prescribing for LD

• Higher risk due to co-morbidities

• Drug interactions e.g. antiepileptics

• BBB dysfunction

• Genetic differences e.g. down syndrome

• Difficulty communicating side effects

  • Missing side effects ‘diagnostic overshadowing

How can we prevent prescribing associated side effects and hazards

Start low and go slow

• Monitor for deterioration in seizure control

• Mood/behaviour changes

• Cognitive side effects e.g. antimuscarinics

• Mobility impairment/ falls

• Weight gain

• Swallow difficulties use NEWT guidelines

How is PK altered in LD

Down syndrome patients have altered blood brain barrier

This leads to higher plasma concentrations of drugs e.g. Donepezil

Which leads to higher rates of adverse effects e.g. GI symptoms, altered ,mental state

Require more monitoring and caution

What is does the acronym STOMP-LD stand for

Stopping

Over

Medication of

People with learning disabilities, autism or both

What is the purpose of STOMP-LD

NHS England initiative

• improves quality of life

• ensures psychotropics are used for the right reason, right dose, right time

• Promotes non-drug interventions

• Improves shared decision making

Is there medication for the core symptoms of autism

No

These people should not be offered antipsychotic unless they are psychosocial or other interventions are insufficient 

How can we treat challenging behaviour: Antipsychotics

Used at low doses if other interventions fail

Examples: Aripiprazole, risperidone

S/E: high monitoring burden of weight, ECG, blood

Aripiprazole and Fluoxetine can be used in severe CB if no effective psychosocial interventions

How can we treat challenging behaviour: Antidepressants

Trial SSRIs to treat underlying anxiety and depression, may help correct difficult behaviour

E.g.: Fluoxetine

What are some other options for LD CB

Propranolol: somatic anxiety

Naltrexone: self injury

What monitoring is involved in LD

Plan for discontinuation (if for CB).

Monitor weight, BMI, and lifestyle (antipsychotics).

Monitor bloods (U&Es for hyponatraemia with SSRIs, prolactin with Risperidone).

The use of anticonvulsants in learning disabilities

Anticonvulsants: RARE

But valproate can be used 

• annual risk acknowledgment form, regardless of capacity

• Pregnancy prevention program

Sultiame: A red drug, initated by specialist, may not be suitable for everyone

Lacosamide: some patients experience improved cognition 

ALL PATIENTS MUST BE REGULARLY REVIEWED

What is a best interests decision

People must act in your best interests before taking certain steps that affect you while you lack capacity. This includes taking certain steps relating to your care and treatment.

Considers your condition, age, wishes, circumstances

CYP inducers and inhbitors

How do we treat dementia and downsyndrome in LD

Fluoxetine and donepezil

But we have to be cautious as down syndrome patients have altered metabolism

This can lead to toxicity especially when combined with CYP inhibitor fluoxetine

Higher risk for ADV and interactions

How can we improve communication with LD

V: validation

E: emotion

R: reassurance

A: activity

Check their understanding by asking to repeat back

Take you time this can be life saving